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Full text of "United States Navy Medical News Letter Vol. 26, No. 8, 21 October 1955"

NavMed 369 




Editor - Captain L. B. Marshall, MC, USN (RET) 



Vol. 26 Friday, 21 October 1955 No. 8 



TABLE OF CONTENTS 

Graduate Training in Navy Hospitals 2 

SPECIAL NOTICE 3 

Current Concepts of Pulmonary Edema 5 

Use of Pentaerythritol Tetranitrate 7 

Pleuropulmonary Tularemia 8 

Spontaneous Hypoglycemia 10 

Improved Coal Tar Ointment ..... . , 12 

Scleroderma 13 

Massive Hemoptysis » • ; .... . . . i 14 

Treatment of Preeclampsia and Eclampsia ■ * • • • ■ • • • 17 

Prevention of Acute Nephritis . . . ^. . i. . v 20 

Residual Motor-Skeletal Disabilities Among 215 Motorists .... ^ . .: 22 

Cutting Properties of Dental Burs » 24 

From the Note Book ... . . i. . . : 26 

Defective Medical and Dental Material (BuMed Inst. 6710. 20). , . . . . ■. . i 28 

Fixed Medical Treatment Facilities {BuMed Inst. 11110. 1) . . , , . ^ . . ,, . i 28 

Influenza Vaccine (BuMed Notice 6230) , 28 

MEDICAL RESERVE SECTION V. . ,7l;;^- ' 

Seminar for Commanding Officers of Reserve Cor .pabies .. ... . ..... . 29 

On-the- Job Training in Submarine Medicine . , 29 

Gratuitous Points . . . .... . . . 30 

AVIATION MEDICINE SECTION • , ■ ■ : .. i - ■ : . ■! 

Course in Aviation Medicine 31 

Air Development Squadron . . . . ... ....... , 31 

Attention, All I light Surgeons ! , . .... 34 

National Air Show Exhibit . . . . .. . . ... . . ., , . , . , 35; 

Examinations of Pilots Following Hospitalization. . . . . . . . i . . . . 35 

Respiratory Chemistry - Gaseous Exchange 35 

Symposium on Physiologic and Pathologic Effects of Microwaves 38 

Historical Facts for October „ 39 



2 



Medical News Letter, Vol. 26, No. 8 



Gradu ate Training in Navy Hospitals 

Applications for assignment to residency training duty are desired from 
Regular medical officers and those Reserve medical officers who have 
completed their obligated service under the Universal Military Training 
and Service Act, as amended. The following chart lists those Navy hospitals 
which currently have vacancies at the first year level, and the specialties 
in which these vacancies exist. Vacancies are also available at other than 
first year levels. Information concerning non- first year appointments may 
be obtained by correspondence addressed to the Chief of the Bureau of 
Medicine and Surgery. 




Anesthesia 


X 


X 


X 










General Practice 




X 






X 






Internal Medicine 




X 




X 


X 


X 


X 


Neurology 


X 






X 








Orthopedics 


X 


X 












Otolaryngology 






X 


X 








Pathology 


X 




X 


X 




X 




Pediatric s 






X 










Psychiatry 


X 




X 


X 








Radiology 


X 


X 


X 






X 




Surgery *** 










X 


X 


X 


Urology 














X 


Cardio- Vascular Diseases 


X 















*** Residency training in General Surgery is currently open to 
Regular officers only. 



Letters of application for first year assignments should be forwarded via 
official channels to the Chief of the Bureau of Medicine and Surgery, and 
should include an obligated service agreement prepared in accordance with 
the provisions of BuMed Instruction 15Z0. 7 



* * * 



Medical News Letter, Vol. 26, No. 8 3 



SPECIAL NOTICE 

TO ALL ADDRESSEES (EXCEPT U. S. Navy and Naval Reserve 
personnel on ACTIVE DUTY and U. S. Navy Ships and Stations) . 

Existing regulations require that all Bureau and office mailing lists 
be checked and circularized at least once each year in order to eliminate - 
erroneous and duplicate mailings. 

It is, therefore, requested that EACH RECIPIENT of the U.S. Navy 
Medical News Letter (EXCEPT U.S. Navy and Naval Reserve personnel 
on ACTIVE DUTY , and U. S. Navy Ships and Stations) fill in and forward 
immediately the form appearing below if continuation on the distribution 
list is desired. 

Failure to reply to the address given on the form by 15 December 
1955 will automatically cause your name to be removed from the files. 
Only one (1) answer is necessary. Please state the branch of the Armed 
Forces (if any) and whether Regular, Reserve, or Retired. Also, please 
write legibly. If names and addresses cannot be deciphered, it is impos- 
sible to compare them with the addressograph plates. 

Editor 



(Detach here) 
Chief, Bureau of Medicine and Surgery 

Navy Department, Potomac Annex (date) ~~ ~ 

Washington 25, D. C. 

I wish to continue to receive the U. S. Navy Medical News Letter, 

Name ' ■ ■ — 

or ■ ' 
Activity ' R e t 

or (Print or type, last name first) (rank, service, corps) 

Civilian Status 



Address 

(number) (street) 
City Zone State 



(Signature) 

(Please print clearly. Only one answer is necessary. ) 



Medical News Letter, Vol. 26, No. 8 



5 



Policy 

The U. S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical De- 
partment of the Regular Navy and Naval Reserve to timely up-to-date items 
of official and professional interest relative to medicine, dentistry, and 
allied sciences. The amount of information used is only that necessary to 
inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be nor 
susceptible to use by any officer as a substitute for any item or article in 
its original form. All readers of the News Letter are urged to obtain the 
original of those items of particular interest to the individual. 

if: >!<>}: 4^ ^ it: 

Notice 

Due to the critical shortage of medical officers, the Chief, Bureau 
of Medicine and Surgery, has recommended, and the Chief of Naval Person- 
nel has concurred, that Reserve medical officers now on active duty who 
desire to submit requests for extension of their active duty for a period 
of three months or more will be given favorable consideration. 

/ - - .• ■ ■ 

Current Concepts of Pulmonary Ed ema 

Pulmonary edema may be defined as the transudation of plasma into 
the alveoli and its extension by air currents into the passages of the res- 
piratory tract. 

The basic factors that are involved in pulmonary edema, as they 
affect the pulmonary capillary, are: {1) hydrostatic pressure, (2) intra- 
thoracic pressure, (3) protein osmotic pressure, (4) capillary permea- 
bility, and (5) lymphatic "run off. " The clinical picture of pulmonary 
edema has been well described and need not be discussed at this time. 

Pulmonary edema, when not adequately treated, kills because of 
uncorrected anoxic anoxia and hypercapnia. Every effort toward the pre- 
vention of pulmonary edema should be made. The patient who seems likely 
to go into pulmonary edema should be affected favorably by rest, digitalis, 
diuretics, salt balance, water regulation, and sedation. 

Granted that a patient is properly prepared and must undergo surgery, 
it is wise to add the antibiotic preoperatively. During surgery, every effort 
must be made to maintain a clear airway. An obstructed airway will aug- 
ment the negative intrathoracic pressure and result in pulmonary edema. 
Blood loss must be accurately replaced so that over -transfusion with rapid 



6 



Medical News Letter, Vol. 26, No. 8 



hypervolemia does not result. The use of weighing scales in the operating 
rooms to determine blood loss is a useful adjunct to prevent overtrans- 
fusion. Saline and other fluids should be administered with caution during 
operation and in the postoperative period. It is best to be on the safe side 
and administer less than the so-called required amount of fluids to the 
patient who seems a likely candidate for pulmonary edema. Constant atten- 
tion to bronchial toiletry is also important. These patients should be encour- 
aged to cough and move about in the postoperative period. Prevention of 
abdominal distention will aid in the prevention of pulmonary edema by 
allowing for greater ventilatory movements of the diaphragm and mitigating 
abnormalities in the abdomino-thoracic venous pressure gradient. 

Once pulmonary edema is present, immediate treatment should be 
instituted. Oxygen should be administered because it serves the obvious 
purpose of facilitating correction of the generalized anoxia that results 
from pulmonary edema. The authors have been particularly impressed with 
the use of oxygen given under positive pressure breathing with a Bennett 
valve. Intermittent positive-pressure breathing tends to diminish the vol- 
ume of blood entering the right heart and, therefore, the lungs. It also 
tends to widen the bronchial pathways. Recently, Luisada has added alcohol 
vapor to the intermittent po sitive -pre s sure breathing and has found it bene- 
ficial because of its antifoaming action. 

Morphine alone will alleviate a large number of attacks. It can be 
administered intravenously. Caution is advised in the elderly patient and 
in those with pulmonary emphysema. Morphine acts by alleviating the 
labored breathing and concomitant decrease in intrathoracic pressure 
which tends to increase pulmonary edema. 

Digitalization is obvious. The rapid acting glycosides are most fre- 
quently used. 

From a clinical standpoint, bloodless phlebotomy (tourniquets) and 
phlebotomy are the most direct means of producing a decrease of the inflow 
load in the right heart. These measures will allow for an increase in vital 
capacity and occasionally lead to an increase in the arterial blood saturation. 
The cerebrospinal fluid pressure falls after venesection, a factor that may 
tend to relieve dyspnea. However, it should be borne in mind that all these 
favorable actions must be balanced against the possibility that shock may 
be precipitated by venesection with a resultant lowering of cardiac output. 

Aminophylline, given intravenously or by suppository, has definite 
clinical value. The drug is apparently a powerful relaxant of smooth muscle, 
and, therefore, the element of bronchospasm is relieved. 

Treatment of pulmonary edema associated with chronic congestive 
heart failure is the treatment of the latter disease. At this time, a discus- 
sion of such treatment is not necessary. ' 

Strong mention should be made of two very useful procedures: atro- 
pinization and tracheotomy. Because it has been shown that the parasympathetic 



Medical News Letter, Vol. 26, No. 8 



7 



pathways are involved in pulmonary edema of neurogenic origin (brain 
trauma, et cetera), it became obvious that atropine administration might 
be of benefit. 

In the unconscious and semicomatose patient or the patient with ex- 
tensive fluid in the bronchial tree, one of the finest adjuncts in the treat- 
ment is tracheotomy. The authors found it to be so effective that, when 
tracheotomy is considered, their policy has been that it should be done 
immediately. Tracheotomy accomplishes many things in these patients. 
It by-passes the vocal cords which may be paralyzed and add to intra- 
thoracic pressure. It decreases the respiratory dead space of the mouth 
and pharynx. It allows for a direct passageway into the bronchial tree so 
that fluid can be suctioned out by a physician or a nurse. It allows for 
positive-pressure breathing, if necessary. 

The authors' opinion is that, in severe instances of acute pulmonary 
edema, tracheotomy will achieve a much wider range of usefulness in the 
future than it has in the past. (LCDR I. D. Baronofsky (MC), LT J. W. Cox 
(MC) USNR, Some Current Concepts of Pulmonary Edema: Arch Int. Med. , 
96:375-379, September 1955) 

:^ ;ic »!( 9{c 

Use of Pentaerythritol Tetrani trate 

The therapy of chronic coronary insufficiency is primarily concerned 
with the establishment of compensation in the coronary circulation. The 
treatment must be individualized and must consider all factors involved 
in the development of the disease and its resulting symptoms. In some 
instances, the correction of underlying secondary factors (anemia, cardiac 
decompensation, obesity, and the like) may completely eradicate the symp- 
toms characterized largely by the syndrome of angina pectoris or its 
equivalent. In others, in spite of all the physical and pharmacologic agents 
used, the authors found that many patients continued to be disabled in vary- 
ing degree. 

The lack of adequate treatment for this latter group prompted the 
authors to consider a drug which might be of therapeutic value, Penta- 
erythritol tetranitrate (Peritrate) appeared to be a possible answer to this 
problem, and with this purpose in mind the present study was undertaken. 

Forty-two patients were originally studied. Twenty patients continued 
in the study for approximately 6 months. These patients had an average of 
60.2 years, ranging from 48 to 75. All patients had clinically obvious angina 
pectoris for which all had previously sought medical attention. All patients , 
despite varying frequency or intensity of their pain, got immediate and com- 
plete relief from nitroglycerine taken sublingually although some complained 
bitterly of the side-effects, especially headache. 



8 



Medical News Letter, Vol, 26, No. 8 



The patients were studied for 935 days on pentaerythritol tetranitrate 
and 595 days on placebo. The duration of an individual study ranged from 
30 to 182 days. 

Prior to subjecting results of the study to analysis, the authors had 
an over-all impression that the majority of their patients were benefited 
considerably by pentaerythritol tetranitrate. The enthusiastic comments 
of the patients about the added comfort, increased relief from pain, and 
relative elimination in the frequency and quantitative need for nitroglycerine 
prompted this opinion. 

From this study, the authors concluded that pentaerythritol tetra- 
nitrate was of decided value in the treatment of 25% of patients with chronic 
coronary insufficiency. Except for the findings of Riseman, the results are 
significantly different from those previously reported. However, because 
of the difficulty in managing this disease adequately with the therapies now 
available, the authors believe that this drug should be considered seriously 
as a positive addition to the pharmacologic treatment of angina pectoris. 
They are of the opinion that in some patients with this illness pentaeryth- 
ritol tetranitrate may mean the difference between complete - or almost 
complete - absence of symptoms, or a prolonged illness with much suffer- 
ing. (Rosenberg. H.N. , Michelson, A. L. .The Use of Pentaerythritol 
Tetranitrate in Chronic Coronary Insufficiency: Am. J. Med. Sc. , 2 30 : 
254-257, September 1955) 

Pleuropulmonary Tularemia 

Due to the great advances made in chemotherapy in the last decade, 
specific treatment of certain types of pneumonia is now possible. Because 
of this, the roentgen differentiation as to etiology is becoming increasingly 
important. This report is based on the roentgen study of 16 patients with 
pleuropulmonary tularemia. An attempt was made to determine if there 
was any characteristic feature in the conventional anteroposterior chest 
roentgenogram which would lead one to suspect the nature of the pneumonia. 

The disease is usually divided into three clinical forms: ulceroglan- 
dular, oculoglandular, and typhoidal types. Pneumonia may occur in any 
form. The portal of entry into the lungs is not always clear. In this series, 
8 cases fell into the typhoidal types, and 8 cases were of pneumonia second- 
ary to ulceroglandular tularemia. The fact that a large number of patients 
with tularemic pneumonia have no primary tularemic ulcer of the skin or 
mucous membrane, and that early clinical diagnosis of tularemic pneumonia 
is frequently difficult makes it very desirable to find some characteristic 
roentgen finding which would lead the physician to suspect P . tularensis 
as the etiological agent of the pneumonia. The clinician can then carry out 



Medical News Letter, Vol. 26, No, 8 



9 



other tests which will prove the diagnosis. This is particularly important 
because the mortality rate of untreated tularemic pneumonia is high and 
treatment by streptomycin is usually curative. 

In the present series, the records of 34 patients with tularemia, 
treated at the Veterans Hospital, were reviewed. Eleven (31%) of these 
had definite pulmonary involvement and were classified as pleuropulmon- 
ary tularemia. The diagnosis was based on a rising serum agglutinin titer 
against P tularensis. Serial 14- by 17-inch chest roentgenograms were made 
on each patient. The study of these, plus 5 cases of pleuropulmonary tula- 
remia treated at Vanderbilt University Hospital, comprises the basis of this 
report. 

Notably, in 9 of the 16 cases, there was an oval area of infiltration 
seen on the first chest roentgenogram. This varied in size and location. 
Its peculiar round appearance was similar to that of an abscess before the 
occurrence of cavitation. In one case, it resembled a large metastatic 
nodule. In another, it was masked by pleural effusion but could te seen 
following the removal of the fluid. This was the most constant and notable 
finding. In one case, a patchy area of density scattered throughout the left 
upper lobe was present. This was indistinguishable from pulmonary tuber- 
culosis. In only 5 cases, was hilar adenopathy a significant finding. In one 
of these cases, the diagnosis was suggested by one of the roentgenologists 
in the hospital from the chest roentgenogram alone. In 10 cases, the pleura 
was involved and manifested by varying degrees of pleural effusion. In 
some instances, fluid was not seen in the pleural cavity on the first exam- 
ination, but as the disease progressed pleural effusion became manifest. 

Although there was no one single sign that could be attributed to 
tularemia alone, it is believed that the common occurrence of an oval area 
of infiltration, not usually seen in other pneumonias, is a noteworthy find- 
ing. This seems to fit the known pathological findings of a confluent lobular 
pneumonia with an appearance similar to that of caseous tuberculous pneu- 
monia. This finding alone or in the presence of enlarged hilar lymph nodes 
should certainly lead one to consider the possibility of tularemia as the 
etiology of the pneumonia, although it is not pathognomonic of tularemia 
alone. In most cases, the presence of pleural fluid seemed to occur in 
relation to the length of the disease. It is believed that the presence or 
absence of pleural fluid will be of no special benefit in the differential diag- 
nosis. (Ivie, J. McK. , Roentgenological Observations on Pleuro- Pulmonary 
Tularemia: Am. J. Roentgenol. , 74: 466-471, September 1955) 

The printing of this publication has been approved by the Director 
of the Bureau of the Budget, 16 May 1955. 



10 



Medical News Letter, Vol. 26, No. 8 



Spontaneous Hypoglycemia 

That periodic spontaneous hypoglycemia is the cause of significant 
and sometimes alarming symptoms in a relatively large number of patients, 
has become apparent to most physicians. 

This presentation has four major purposes: (1) to outline again the 
whole problem, incorporating recent additions to present knowledge and 
rejecting discredited concepts; (2) to demonstrate the clinical usefulness 
of a few simple, but rigid, criteria in establishing the specific etiologic 
diagnosis in more commonly encountered and confusing types of spontan- 
eous hypoglycemia; (3) to discuss rational therapy for the various types, 
based upon present concepts of the abnormal mechanism which produces 
hypoglycemia in each instance; and (4) to attempt to prevent unnecessary 
pancreatic explorations and subtotal pancreatectomies inpatients who 
exhibit no indication for such procedures. 

Spontaneous hypoglycemia is not a disease. It is an indication of a 
derangement in the over-all utilization of carbohydrate in which glucose 
has been removed from the blood at a rate faster than it has been replen- 
ished, with a resultant depression of the blood sugar to an abnormally low 
level. As indicated in this report, many organic and functional lesions 
exist, any one of which is capable of increasing the rate of removal of 
glucose from the blood and/or of decreasing its rate of entry into the blood. 
Recognition of this fact constitutes the first step toward an intelligent ap- 
praisal of the mechanism by which hypoglycemic episodes are produced in 
any given patient. 

By definition, the term excludes hypoglycemia induced by the admin- 
istration of exogenous insulin, but in the evaluation of the patient suffering 
from spontaneous hypoglycemia, the possibility of a factitious cause {self- 
administration of insulin) must always be in mind. Also, by definition, 
the term excludes the concept of "relative hypoglycemia" which has crept 
into the literature to cause confusion in both diagnosis and management. 

Spontaneous hypoglycemia and hyperinsulinism are not synonymous 
terms. The former is the generic term. It includes all clinical situations 
in which the blood sugar may fall to abnormally low levels spontaneously. 
The term hyperinsulinism is confined t© those types of spontaneous hypo- 
glycemia in which an absolute increase in the production of endogenous 
insulin is believed to occur. 

Unusual manifestations of hypoglycemia, as well as their relation to 
the actual level of the blood sugar, have often caused confusion in diagnosis. 
At opposite poles of the spectrum of symptoms, are two distinct clinical 
pictures. The appearance of one pattern or the other, or of a combination 
of the two, is determined, not only by the level of the blood sugar but also 
by the rate at which it has fallen and the duration of the hypoglycemia. If 
the rate of fall in blood sugar is rapid, the predominant, early symptoms 



Medical News Letter, Vol. Z6, No. 8 



11 



are those produced by compensatory hyperepinephrinemia. This mech- 
anism represents an attempt to restore normal blood glucose levels by 
accelerating hepatic glycogenolysis. The symptoms are those which are 
observed during a mild reaction after administration of too much soluble 
insulin, and consist of sweating, weakness, hunger, tachycardia, and 
"inward trembling. " Conversely, if the blood sugar falls slowly to low 
levels over a period of many hours, the manifestations are cerebral in 
type: headache, visual disturbances, mental confusion, coma, and convul- 
sions. If the decrease in blood glucose is rapid, profound, and persistent, 
the initial symptoms due to excessive circulating epinephrine merge with 
those of cerebral hypoglycemia. 

When the blood sugar concentration remains low for most of the 
24-hour period, a situation which may occur in organic hyperinsulinism, 
the manifestations of hypoglycemia may be so bizarre as to be completely 
misleading. Any aspect of the entire range of neurologic or psychiatric 
disorders may be mimicked, including sensory or motor loss of an extrem- 
ity, hemiplegia, outbursts of temper, extreme depression, or apparent 
catatonic schizophrenia. Despite the atypical nature of symptomatology in 
some individuals, it is of interest that the same complex of symptoms tends 
to recur in the same patient. In the authors' experience, periodicity of symp- 
tomatology represents a more important diagnostic hint of underlying hypo- 
glycemia than the specific type of complaint which is offered. The repetitive 
nature of the complaint, occurring at fairly specific times during the 24-hour 
period, should arouse suspicion. The demonstration of hypoglycemia during 
an attack, together with dramatic relief of symptoms with intravenously 
administered glucose, establishes only the nonspecific diagnosis of spon- 
taneous hypoglycemia. The specific etiologic diagnosis must be established 
at this time if rational and effective therapy is to be applied. 

It is beyond the intent of this presentation to attempt to discuss the 
body's complex physiologic mechanisms which, when properly integrated, 
result in normoglycemia. Mention of the more important tissues, organs, 
and endocrine glands involved is sufficient to impress one with the mul- 
tiplicity of possible aberrations which can upset the delicately balanced 
level of blood sugar. The list includes the central nervous system, the 
autonomic nervous system, the gastrointestinal tract, kidneys, liver, 
muscles, pancreas, adenohypophysis, adrenal cortex and medulla, and the 
thyroid. 

Some situations are listed which are associated only rarely with 
hypoglycemia but are included for purposes of more complete classification. 
The more commonly encountered types are discussed in detail, (Conn, J. W. , 
Seltzer, H. S, , Spontaneous Hypoglycemia: Am, J. Med., XIX: 460-475, 
September 1955) 



4: si'! si;: ^ ^ 



12 



Medical News Letter, Vol. 26, No. 8 



Improved Coal Tar Ointment 

A 1% crude coal tar ointment, in which the tar is finely divided and 
dispersed uniformly by the addition of 0. 5% of polyoxyethylene sorbitan 
monolaurate (Tween 20), a nonionic surfactant, prior to incorporation 
with zinc oxide paste, has proved to be clinically effective, while producing 
about one-fourth as many reactions of cutaneous irritation as occurred in 
the use of 2% and 5% crude coal tar in zinc oxide paste prepared by standard 
methods. 

One percent of crude coal tar and 0. 5% of polyoxyethylene sorbitan 
monolaurate, a hydrophilic surface -active agent, are thoroughly mixed and 
then incorporated with zinc oxide paste U. S. P. XIV. The resulting ointment 
is a uniform, smooth preparation of a medium gray color and moderate tar 
odor. Microscopically, the tar particles are very fine and uniformly dis- 
persed throughout the vehicle. The ointment is easily compounded extempo- 
raneously by the independent pharmacist. 

As a convenience in identification, the name "solutar ointment" was 
applied to this preparation. It is a misnomer because this is not a soluble 
tar ointment. In practice, the ointments are labeled "1 and 1/2% Solutar 
in Lassar's Paste, " and represent a 1% crude coal tar ointment. The terra 
"solutar" refers specifically to the initial mixture of crude coal tar with 
polyoxyethylene sorbitan monolaurate. 

Throughout the first 14 years of this study, the use of tars was ser- 
iously restricted because their irritant properties were so great. Many 
patients came from distances of 100 to 300 miles and close observation 
was often impossible. The general policy was to withhold crude coal tar 
unless there was opportunity to observe the patient for at least a few days. 
Even so, the 10% incidence of reactions was higher than was expected. 

During the last 4 years, the policy has changed completely. The 
"solutar" ointment is prescribed freely, regardless of the opportunity for 
observation. A simple warning is given to discontinue the medication 
should untoward results appear, and this same warning is given with the 
mercurials, quinolines, and the antibiotic s. 

Moreover, there has been a change in the type of dermatitis for which 
the tars are prescribed. In the past, their use was restricted to extremely 
chronic dermatoses, such as psoriasis, lichen simplex chronicus, and 
hypertrophic lichen planus. The trend at present is toward the use of crude 
coal tar on somewhat more acute, active dermatitis. The clinical results 
of the trend are encouraging, and the trend itself makes the lowered inci- 
dence of reactions all the more remarkable. 

Carefully controlled, statistically significant studies on the types of 
reactions encountered have not been carried out. It appears from patch 
tests and re-exposures that the majority of reactions are irritative, and 
in the minority, specific contact allergies. The authors' impression is 



Medical News Letter, Vol. 26, No. 8 



13 



that the fine dispersion of the tar in the "solutar" formulation has reduced 
the number of these nonspecific irritative reactions without materially- 
affecting the frequency of hypersensitiveness. 

Relatively limited clinical studies on indigent as well as private 
patients regarding the comparative virtues of the zinc oxide paste and the 
hydrophilic ointment vehicles for the "solutar" formulation, seem to indi- 
cate that the oleaginous paste is the better base. This is perhaps due to 
better adhesion to the skin, better protection against mechanical and chem- 
ical trauma, greater occlusiveness, and the generally dry scaly character 
of the skin most frequently treated with tars. The hydrophilic base has been 
definitely preferable only when hairy areas are involved. 

In spite of the effectiveness of hydrocortisone ointments with their 
more pleasing physical attributes, no truly satisfactory substitute for crude 
coal tar has yet appeared. The need for an effective and relatively safe 
crude coal tar ointment remains great, and the authors' experience with 
the so-called "solutar" ointment indicates that this ointment is an important 
advance in dermatologic therapy. (Carney, R.G. , Zopf, L. C. , An Improved 
Coal Tar Ointment Using a Surfactant: Arch. Dermat. , 72: 266-269, Septem- 
ber 1955) 

sic 3|c ^ ^ 9{: 

Scleroderma 

Scleroderma is an uncommon, though not a rare disease. Most 
physicians see few cases and, therefore, patients affected with this con- 
dition are difficult diagnostic problems. At considerable financial and 
emotional expense, they migrate from one physician to another seeking a 
satisfactory explanation for their illness. 

Scleroderma is a generalized disease of unknown etiology. The fun- 
damental pathologic change is sclerosis of the connective tissue framework 
of the skin and other organs. This disease has been classified as a collagen 
disease along with lupus erythematosus, periarteritis nodosa, rheumatoid 
arthritis, rheumatic fever, dermatomyositis, and possibly thrombotic 
thrombocytopenic purpura. The collagen system or connective tissue 
lesions in these diseases constitute the primary pathologic changes. It is, 
however, a nonspecific pathologic process and does not separate these 
disease entities from one another. It may not even Indicate a common 
etiologic denominator. 

Scleroderma is more common in women than men (1. 5 to 1) in the 
fourth to the sixth decades, though it may occur at almost any age. The 
onset of the disease is usually either the gradual onset of Raynaud-like 
phenomena, usually involving the hands and sometimes the feet, or an 
acute or subacute illness that may be quite mild, characterized by 



14 



Medical News Letter, Vol. 26, No. 8 



arthralgia or arthritis, myalgia, a variable skin eruption, and malaise. 
The course is extremely variable. The onset may be insidious with many 
years required for its full development, or the disease may appear and 
progress to a fatal termination in a few weeks. Constitutional symptoms 
are variable. Nearly all patients lose weight when the disease is active, 
and this is not necessarily related to involvement of the gastrointestinal 
tract. About half the patients notice weakness or increased fatigability 
and some run a low-grade fever. There is usually muscle atrophy and this 
is not necessarily correlated with the hide -bound state of the skin. Mild 
arthritis is present in the majority of patients. This consists mainly of 
stiffness, joint pain, or swelling. In the early stages, it involves soft 
tissue and seldom produces x-ray changes. 

Scleroderma is difficult to diagnose when it masquerades as a single 
visceral disease. Its similarity to, and differentiation from, Raynaud's 
disease and scleroderma adultorum have been mentioned. In the early 
edematous stages, it may superficially resemble myxedema. However, 
the characteristic physical and laboratory finding of myxedema are absent. 

The most difficult disease to differentiate is dermatomyositis. In 
dermatomyositis, there is initially a rose -pink erythema and edema of the 
face, eyelids, and extremities, with progressive pain, weakness, and 
atrophy of various groups of muscles. In scleroderma, there may be mus- 
cle atrophy, and in the early edematous stage of skin changes, the two 
diseases are quite similar. In this stage, one may not be able to differen- 
tiate these diseases by biopsy. In later stages, the fundamental skin change 
in scleroderma becomes quite characteristic. It should also be noted that 
there is never pulmonary involvement due to dermatomyositis. 

The cause of scleroderma is unknown, although at one time or another 
most of the endocrine glands have been suspected. More recently, sugges- 
tions have been made that the disease is a psychogenic or allergic one- 
Over the years, many forms of therapy have been used, including 
most of the available hormones, vitamins, diets, surgical procedures 
(sympathectomy) and, more recently, para-aminobenzoic acid. None has 
been consistently useful in checking the course of scleroderma. ACTH 
and cortisone may give mild, transient relief in some cases. (Butler, J. J. , 
Scleroderma: GP, XII : 103-107, September 1955) 

3^ 9{( sj: ^ i{c 

Massive Hemoptysis 



Hemoptysis is a symptom frequently encountered in diseases of the 
cardiac and pulmonary systems. The bleeding may be slight in amount and 
only stain the sputum or expectorated purulent material. Sudden, severe 
hemoptysis is probably one of the most alarming things which may happen 



Medical News Letter, Vol. 26, No, 8 15 

to a patient and, occasionally, during a massive hemorrhage, death may- 
result. This article is concerned only with the type of patients who have 
severe pulmonary bleeding which, if continued, would constitute an immed- 
iate threat to life. 

In a group of patients under observation, hemoptysis frequently 
amounted to more than 500 cc. during one episode. In some patients there 
was no previous history of pulmonary disease and the bleeding was the 
initial symptom. Death may result either by drowning in aspirated blood 
or actually by exsanguination. The authors encountered 12 such patients 
during the last 5 years on the Surgical Service of the State University of 
Iowa Hospitals. Thoracotomy and pulmonary resections were performed 
to stop the bleeding from the pulmonary tract. Active pulmonary tubercu- 
losis or pulmonary neoplasms were not etiological factors in this group. 
Frequently, the erroneous diagnosis of a pulmonary neoplasm had been 
made prior to surgical exploration in spite of the knowledge that hemoptysis 
in patients with a bronchogenic carcinoma is usually a late symptom. The 
authors did not include patients with generalized disease which might cause 
bleeding; neither did they include patients with primary cardiovascular 
diseases of congenital or acquired nature. The most frequent causes for 
hemoptysis are quoted to be: bronchiectasis, pulmonary abscesses, and 
pulmonary tuberculosis. Acquired cardiac disease, as for instance mitral 
stenosis, may be the cause of hemoptysis of moderate degree, while con- 
genital cardiovascular lesions very rarely produce pulmonary bleeding. 

All patients were considered to be in good health prior to the onset 
of the severe hemoptysis, with the exception of one. As has been mentioned 
by various authors, the degree of hemoptysis bears no relationship to the 
gravity of the underlying pulmonary disease. In each instance, the under- 
lying primary cause, itself, was not a threat to life except for the production 
of the massive bleeding. This can be illustrated by the pathologic findings 
in this group of patients. Bronchiectasis of mild degree was demonstrated 
in 2 patients, broncholithiasis, or calcified peribronchial lymph nodes in 
6 other patients. No specific cause for the massive bleeding could be found 
in the remaining 4 cases. 

The main preoperative problem is the exact localization of the site 
of hemorrhage. Occasionally, patients will be able to state from which 
lung they believe the bleeding arises. This was the case in one -half of 
the patients in this series. A vague sensation of discomfort or pain may 
be present. Splinting of the involved side may be noted. Physical findings 
may be helpful but are also misleading due to the involvement of other 
portions of the lungs by aspirated blood. Roentgenograms of the chest 
frequently will help in localization of the lung which is the source of the 
hemorrhage, but may be misleading in the localization by lobes or pul- 
monary segments. The visualization of calcific peribronchial nodes in the 
chest roentgenogram appeared to the authors to be very significant. 



16 



Medical News Letter, Vol. 26, No. 8 



Planograms and roentgenograms in different positions of rotation are 
helpful in the demonstration of the anatomical relationship of the calcific 
masses or peribronchial nodes to the bronchial tree. Bronchography may 
at times be valuable but usually is of limited usefulness during the active 
phase of bleeding. It is not only difficult but also may be misleading due 
to the blockage of different portions of the tracheobronchial tree by aspi- 
rated blood. Demonstration of bronchiectatic changes by Lipiodol instil- 
lation during quiescent periods is of the greatest importance. 

In the opinion of the authors, the most valuable procedure which must 
be carried out in all patients with hemoptysis, is bronchoscopy. This inves- 
tigation must be done during the time of active bleeding. The source of 
bleeding may not be visualized directly but, at least, it will be possible 
to determine the lobar, or occasionally, the segmental bronchus from 
which the blood is coming. This procedure must be done with the greatest 
care. Removal by suction of all endobronchial clots is essential. The vis- 
ualization of fresh blood coming from a bronchial orifice under these cir- 
cumstances can then be taken as certain and the proper localization of the 
source of hemorrhage. Facilities for immediate thoracotomy should be 
available at that time. Reactivation of severe bleeding has occurred in 
some patients in this series necessitating emergency pulmonary resection 
as a lifesaving procedure. A delay in carrying out bronchoscopy until 
bleeding has stopped may not be possible and is also undesirable. The 
opportunity to localize the site of hemorrhage may have passed by that 
time. 

The authors believe that an episode of massive hemoptysis is a 
definite indication for exploratory thoracotomy. As soon as all possible 
and indicated diagnostic procedures have been completed in an attempt 
to localize the site of hemorrhage, surgical exploration should be per- 
formed. Lobar, and if possible, segmental localization is certainly 
desirable but exploration should not be withheld if the side from which 
the bleeding arises has been demonstrated. Prolonged observation , with 
the hope that a massive hemoptysis may stop, usually leads to further dif- 
ficulties. Frequently, the patients may show some reduction of the amount 
of hemorrhage, only to resume severe bleeding at unexpected moments. 
Invariably, the patients develop extensive aspiration pneumonitis, atelec- 
tasis, and later, pulmonary infections. This may happen in spite of all 
efforts to prevent aspiration into the opposite bronchial tree and even with 
the best possible measures to protect the noninvolved pulmonary tissue. 
Reduction of functioning lung tissue further decreases the patient's chances 
for survival during, or recovery after, surgical intervention. 

Protection of the contralateral bronchial tree from aspiration of blood 
is most important. Positioning the patient to promote adequate drainage 
may be of value. Mild sedation to promote rest but not enough to reduce 
the cough reflex is advisable. Other forms of conservative treatment, in 



Medical News Letter, Vol. 26, No. 8 



17 



an attempt to reduce the pulmonary bleeding are, in the opinion of the 
authors, not indicated in this group of patients. Temporary or permanent 
collapse procedures of one type or another may be of value in patients with 
pulmonary tuberculosis in whom immediate resection is not advisable. 

The problem of the management of massive life -threatening hemop- 
tysis due to nonmalignant and nontuberculous disease is presented. The 
authors believe that massive hemoptysis constitutes an indication for 
thoracotomy as soon as localization of the bleeding site has been estab- 
lished. Preoperative diagnostic procedures for localization of the site of 
hemorrhage are described. Bronchoscopy during an episode of bleeding 
is essential. Information gained by this investigation will guide the rational 
surgical management to a great extent and prevent unnecessary sacrifice 
of pulmonary tissue, inasmuch as operative findings in themselves are often 
misleading. Broncholithiasis or calcific peribronchial lymph nodes were 
found to be frequent causes of massive pulmonary bleeding. Resection 
therapy in the treatment of these patients has resulted in a low morbidity 
rate and no mortality, {Ehrenhaft, J. L. , Taber, R. E. , Management of 
Massive Hemoptysis, not Due to Pulmonary Tuberculosis or Neoplasm; 
J. Thoracic Surg. , 30: 275-283, September 1955) 

3|c sic >!; :^ »!c 

Treatment of Preeclampsia and Eclampsia 

The best criterion for successful management of eclampsia is the 
use of a regimen of therapy with which the physician is thoroughly familiar. 
His armamentarium should include experience, knowledge of what a given 
form of treatment should do, and a constant awareness of the complications 
which frequently accompany eclampsia. He should always have a definite 
plan in mind, and if improvement is not apparent in a given period of 
time he should plan to interrupt the pregnancy at the safest possible 
moment. 

The incidence of nonconvulsive toxemia varies in large clinics from 
5 to 10%. About 1 of every 10 of these patients suffers from severe toxemia; 
these are the cases to be "weeded out" in early pregnancy. 

When a patient is seen early in pregnancy and has had toxemia in a 
previous pregnancy, a history of hypertension, or of acute or chronic kidney 
disease, or when signs of any of these conditions appear early in pregnancy, 
she should have a thorough work-up, preferably in the hospital. Studies 
should include: (1) examination of urine with Addis count; (2) urea clearance 
test or determination of the concentrating ability of the kidney; (3) deter- 
mination of the amount of protein excreted in the urine per 24 hours; (4) 
ophthalmoscopic examination; and (5) frequent determinations of blood 
pres sure. 



18- 



Medical News Letter, Vol. 26, No. 8 



In general, one may advise the patient that the pregnancy may con- 
tinue if: (1) ophthalmoscopic examination does not disclose extensive 
retinal changes; (2) blood-urea clearance is 50% of normal or higher; (3) 
concentrating ability of the kidney is 1. 020 or more; (4) Addis count is 
not too abnormal; (5) excretion of protein in a 24-hour period is less than 
0. 3 gm. ; and (6) blood pressure is not consistently higher than 170 mm. Hg 
systolic. 

The patient and her husband may desire to continue the pregnancy 
even though the results of these studies are not favorable. One should 
advise them of the dangers to the mother and of the probability that there 
is only about one chance in three that they will leave the hospital with a 
live baby. A note should be placed in the records as to the physician's ad- 
vice and the couple's decision. 

The first abnormal finding in almost all cases of true preeclampsia 
is an abnormal gain in weight early in pregnancy. The pregnant patient's 
weight gain should be limited to 7 or 8 kg. above the ideal for her height 
and age. A weekly gain of 600 gm. or more is definitely abnormal and 
indicates excessive retention of sodium and water. The physician should 
watch constantly for abnormal gains in weight, increase in blood pressure 
to 140/95 or more, or a systolic increase of 30 mm. Hg or more, develop- 
ment of pretibial edema, a trace of 1 plus or more of proteinuria, or other 
abnormal findings. If any of these occur, one must observe the patient 
more closely, and if the symptoms or signs are of an alarming nature or 
if they appear abruptly, the patient may require hospitalization. It is best 
to err on the side of overestimating the severity of symptoms. This applies 
to the management of all cases of toxemia of pregnancy, even when a phys- 
ician has had years of experience. 

One should never prescribe sedation for a patient with preeclampsia 
who is being managed on an outpatient basis. Such sedation may mask 
important symptoms. The patient is instructed to call her physician immed- 
iately if any symptoms of the condition develop. 

If the condition is not stabilized with the outpatient regimen, the patient 
is hospitalized and observation and treatment of nonconvulsive toxemia are 
begun. 

The aim of treatment is to carry the pregnancy to at least 32 weeks. 
However, if any of the following symptoms or signs persist or increase despit 
active therapy, the pregnancy should be terminated. 

1 Consistent systolic blood pressure of 170 mm. Hg or a 
persistent daily increase 

2 Proteinuria of 5 gm. or more in 24 hours, or a large amount 
as indicated by the qualitative test 

3 Weight gain exceeding 100 gm. per day while the patient is 
adhering to a strict low sodium, low potassium diet. 



Medical News Letter, Vol. 26, No. 8 



19 



4 Marked edema, occurring suddenly 

5 Cerebral, visual, or gastrointestinal symptoms 

6 Oliguria, anuria, or hematuria 

7 Jaundice 

8 Blood nonprotein nitrogen of 50 gm. percent or more 

9 Pulse rate of IZO or more 

10 Edema of the lungs or cyanosis 

11 Concentration of blood as indicated by an abnormally high 
or increasing hemoglobin, cell volume, serum protein 
concentration or specific gravity 



The initial period of observation and treatment of the hospitalized 
patient, therefore, is for the purposes of evaluating the severity of the 
condition, trying to establish a definite diagnosis, and instituting a regimen 
to control the abnormal signs and symptoms. 

The aim of treatment of nonconvulsive toxemia is the prevention of 
convulsions. The maternal mortality rate for nonconvulsive toxemia, as 
reported from seven maternity hospitals, has been 0. 082% , but 8% of the 
mothers die when convulsions occur. 

The accepted method of treating eclampsia consists of medical man- 
agement for 6 or more hours and delivery as soon as it can be accomplished 
safely with the lowest possible maternal mortality. When convulsions have 
been controlled, the patient has been brought out of coma, and a good urinary 
volume has been established, one may wait for the onset of labor for a max- 
imum of 4 or 5 days if the patient has mild eclampsia. 

If a patient presents one or more of the following findings, the authors 
consider her to have severe eclampsia. 

1 Coma 

2 Temperature of 39° C. or more 

3 Pulse rate over 120 

4 Respiratory rate over 40 

5 More than 10 convulsions 

6 Cardiovascular impairment (edema of the lungs, persistent 
cyanosis, low or falling blood pressure, low pulse pressure, 
et cetera) 

7 Failure of treatment to stop the convulsions or prevent their 
recurrence; to produce a blood dilution as indicated by a de- 
crease of at least 10% in the hemoglobin, cell volume or 
serum protein concentration, or to produce a urinary output 
of at least 700 cc. per 24 hours 



With these criteria and the knowledge of what this type of treatment 
should accomplish, one frequently can classify the type of case on admission 



20 



Medical News Letter, Vol. 26, No. 8 



or within 6 to 7 hours. If the case is severe, arrangements are made 
after 8 to 12 hours of medical management to terminate pregnancy by the 
safest method. {O'Keefe, C. D. , O'Keefe, J. K. , Treatment of Preeclamp- 
sia and Eclampsia: Postgrad. Med., J_8: 165-173, September 1955) 

:jc :{( 3[c ;{c 

Prevention of Acute Nephritis 

Both acute rheumatic fever and acute glomerulonephritis are com- 
plications of group A streptococcal respiratory infections. Although signi- 
ficant advances have been made during the past decade in the prevention of 
attacks of rheumatic fever, little attention has been paid to the problem of 
preventive measures for acute nephritis. This is especially surprising 
because both diseases are caused by group A streptococci, and the therapy 
of both the renal and cardiac complications can be considered inadequate 
today. In this present report, the natural history of acute glomerulone- 
phritis is emphasized in an attempt to focus medical attention on those 
features of the disease which may be susceptible to vigorous preventive 
measures. 

The control of rheumatic fever is based on the fact that the disease is 
caused by an infection with group A streptotocci. By the judicious use of 
antibiotics, it is possible to control both initial and recurrent attacks of 
acute rheumatic fever. Theoretically, similar methods should be equally 
effective in the prevention of acute nephritis, but because of certain fun- 
damental differences between the two complications, it is necessary to 
alter the preventive program. 

In the general population, the only practical method presently avail- 
able for the prevention of rheumatic fever is the treatment of the preceding 
streptococcal infection. To be effective, such therapy must eliminate the 
infecting organisms from the host. Chemotherapeutic agents administered 
in inadequate amounts fail to eradicate the streptococcus and do not alter 
the attack rate of acute rheumatic fever. The drug of choice appears to 
be benzathine penicillin, administered as a single injection of 600, 000 to 
900, 000 units. Although early therapy of such infections is advisable, 
treatment instituted as late as the ninth day after the onset of the sore 
throat will still prevent rheumatic fever in the majority of patients. 

The problem of preventing initial attacks of acute nephritis in the 
general population appears somewhat more difficult than the prevention of 
rheumatic fever. 

The failure to prevent renal damage in every patient receiving pen- 
icillin may be due to the short latent period exhibited by many patients 
developing nephritis. Thus, the glomerulus may be damaged early in the 
streptococcal disease, as evidenced by the hematuria occurring during the 



Medical News Letter, Vol. 26, No. 8 



21 



first few days of infection. Under such circumstances, perhaps a mod- 
ification of the nephritic complication is the most one could expect from 
such treatment. In rheumatic fever, the evidence indicates that the 
rheumatic process is initiated late, usually after overt signs of the strep- 
tococcal Infection have subsided. From a practical standpoint, these 
observations emphasize the importance of early treatment of the strep- 
tococcal respiratory disease and indicate the need for the development 
of other preventive measures. 

Following infection with most nephritogenic types of group A strep- 
tococci, the attack rate of acute nephritis is considerably higher than the 
attack rate of rheumatic fever. Furthermore, many inapparent examples 
of acute nephritis develop following infection with these organisms. 

All individuals coming into intimate contact with the patient with 
nephritis should be cultured, and those shown to harbor beta hemolytic 
streptococci should receive an injection of 600, 000 units of benzathine pen- 
icillin. By these measures, the organisms can be limited in spread within 
the family or other population groups. Only by such methods, can the inci- 
dence of nephritis be reduced appreciably. To recommend that acute neph- 
ritis be made a reportable disease so that the public health authorities may 
assist in the development of effective control measures, would appear 
entirely reasonable. 

It is now well established that patients who have had an attack of 
rheumatic fever are especially susceptible to recurrent attacks. From 20 
to 80% of rheumatic patients, experiencing a streptococcal infection, will 
develop a new attack of rheumatic fever. For this reason, continuous 
prophylaxis is recommended for all individuals who have experienced an 
overt rheumatic episode. 

The situation is somewhat different in the case of nephritis. Patients 
who have chronic nephritis frequently develop an acute exacerbation of the * 
disease following a variety of infections. Characteristically, these episodes 
develop soon after the onset of the acute illness and no latent period is 
discernible. The urine specimens from these patients usually contain large 
amounts of albumin as well as numerous red cells and casts. In such 
patients, the acute exacerbation may precipitate an episode of renal failure 
It IS, therefore, advisable to place all patients with signs of chronic neph- * 
ritis on a prophylactic regimen. For this purpose, oral penicillin may be 
administered in doses of 250, 000 units once or twice daily or, as an alter- 
native, a single intramuscular injection of 600, 000 to 900, 000 units of 
benzathine penicillin may be given at monthly intervals. 

Patients, who have developed acute glomerulonephritis following a 
streptococcal infection, usually recover completely and fail to show an 
increased susceptibility to recurrent attacks. 

Emphasis should be given to the need for further knowledge of the 
immune status of the patient who has had acute nephritis. This is especially 



22 



Medical News Letter, Vol, 26, No. 8 



r. 



true today when the majority of patients with acute nephritis receive pen- 
icillin. Such therapy may inhibit type- specific antibody formation, even 
though it is usually administered 10 days after the onset of the streptococcal 
infection. It is possible that a few of these patients will develop a second 
infection due to one of the nephritogenic streptococci, and that second 
attacks of nephritis will be observed. To date, no such instance has been 
described. 

By the intelligent use of penicillin in the therapy of streptococcal 
infections, the incidence of nephritis should decrease. Of special impor- 
tance, is the recognition of the public health aspects of nephritis, because 
the physician has the opportunity to limit the spread of nephritogenic organ- 
isms by the proper prophylactic procedures. {Rammelkamp, C. H. , Jr. , 
Prevention of Acute Nephritis: Ann. Int. Med. , 43: 51 1-517, September 
1955} 

* :{! s|( * * * 

Res idual Motor-Skeletal Disabilities 
A mong 215 Motorists 

Links in the life history of motorists, involved in accidents, comprise 
five groups: those who escape injury, immediate deaths, intermediate deaths 
(within 48 hours), delayed deaths, and survivors after injury. Each group 
has its own set of clinical and epidemiological implications. The present 
series is intended to supplement the fifth group - bridging the gap between 
the hospital discharge and subsequent periods in the clinical life history 
of automotive crash victims. These people were seen by the author in his 
office from late 1949 through July 1955 . as new and ambulatory patients, 
in periods after their accidents which ranged between several months and 
several years. The universality of mechanically produced disabilities 
makes these kin to industrial injuries. 

Crash forces responsible for injuries to vehicular occupants derive 
from vehicular masses, speeds, and the nature of their principal impacts. 
It is noted that 70% of the vehicles were passenger cars and 30% were com- 
merical carriers of one kind or another. About 25% of the accidents did 
not involve crashes between vehicles. 

The incidence and frequency rates of involvement of the various 
bodily areas in this series of patients are illustrated. The neck, low back, 
and lower extremities were about equally affected, the remainder being 
distributed among upper extremities and miscellaneous regions of the 
body. About 85% of the lesions involved the cervical, low back, and lower 
extremity regions. 

Complicating arthritis, as well as the original forces, seem to have 
been responsible for the prolonged periods of disability experienced by 



Medical News Letter, Vol. 26, No. 8 



23 



many of these patients. Undoubtedly, these people had a lowered tolerance 
to the forces they encountered at the time of the accident. Questions 
occurred with regard to aggravation of pre-existent arthritis and to pre- 
ventive measures. 

There were 600 sprains of the low back region. Thirteen percent 
affected persons up to 20 years; 70%, those between 20 and 45 years; 17%, 
those between 45 and 65 years; and none thereafter. From the standpoint ' 
of seating, 62% were drivers, 28% were front seat passengers, and 10% 
were back seat passengers. The types of impacts were similar to those 
which produced neck injuries. 

Of interest, was the observation that the low back situation is at 
the opposite extreme of the spinal column from the very mobile cervical 
portion. Whiplash is not possible in the lower, more massive part of the 
body from the sitting position in the true sense of the phrase. This portion 
of the body is the one most easily amenable to restraint by safety gear 
(belts, et cetera). Properly seated, the lower back is said to be in the 
most relaxed and least vulnerable position to injury. Perhaps more atten- 
tion to automotive seating (proper design) will reduce the number of these 
low back complaints. The same may be said of safety belts. However, 
there are those who fear that the latter would increase whiplash effects' 
upon the cervical region. Low-back disabilities offer another category 
among motorist casualty disabilities which are often lost sight of at the 
time of the accident and immediately afterward. 

Among those with injuries of the upper extremities, 50% sat in the 
right front seat (the only category where drivers were not predominant), 
31% were drivers, and 19% sat in the back seat. Fifty percent of these 
lesions involved the shoulder joint; the remainder were distributed 
equally among elbow, wrist, forearm, and hand. Approximately two - 
thirds affected the soft parts: bursae, muscles, tendons, and joint cap- 
sules. Pre-impact positions determined in part the vulnerability and 
degree of injury sustained by most of these persons. By the same token, 
the difficulties with regard to factors of safety relative to these mobile and 
relatively small bodily masses become apparent and ought to be appreciated 
by the more unreasonable critics of the automotive industry. 

All areas of the lower extremities were involved. Fifty percent were 
drivers, 33% front seat passengers, and 17% were back seat passengers. 
Twenty cases with internal derangement of the knee were of special interest: 
12 meniscal (two lateral); six ligamentous (one cruciate); and one loose 
body and chondromalacia of the patella. Only one of these cases was com- 
plicated by arthritis. Eighteen were noted among younger age groups; 
also one each in the seventh and eighth decades. The remainder of the 
lesions affecting the lower extremities were of the run-of-the-mill variety: 
soft, skeletal, and joint. 



24 



Medical News Letter, Vol. 26, No, 8 



These peripheral lesions (lower extremity) implicate various interior 
design factors (impact areas) almost to the same degree that head, face, 
and chest injuires (acute) do - namely dash, steering column, floor pedals, 
et cetera. Thus, knees impacted dashes, steering columns, and wheels; 
feet entangled foot controls and sometimes were caught in partially opened 
doors (recurrent specter of ejection), under floor mats, under the back 
of the front seat; and occasionally, legs were smashed because they were 
crossed at the time of impact. 

From the seated position, it would appear that bodily restraint by 
seat belt would help to nullify some of the impacts suffered by the lower 
extremities - expecially the knee-dash ones many of which result in frac- 
tures of the patella, femur, and hip joint {fracture dislocations). The 
knee derangements suggest that some of the kinematics of the human body 
under crash conditions exert forces of leverage as well as direct pressure 
effects. 

It is possible that seat belt restraint would minimize this tendency 
by preventing bodily dislocations in the first place. (Kulowski, J. , Residual 
Motor-Skeletal Disabilities Among 215 Motorist Casualties: Indust. Med. , 
24: 395-397, September 1955) 

* !{5 * * * * 

Cutting Properties of Dental Burs 

Research at the National Bureau of Standards dental research labor- 
atory indicates that eccentricity of rotating burs causes vibration at fre- 
quencies distressing to dental patients. The investigators also found 
that high-speed rotations of true-running dental instruments produce vibra- 
tions above the frequencies causing the greatest distress, and that burs 
and diamond wheels cut more effectively at higher speeds. 

Until a few years ago, little was known regarding the cutting action 
of dental burs on human teeth. Data on industrial cutters is not entirely 
applicable to dental instruments because the properties of tooth enamel 
and dentin differ from other materials and because dental instruments are 
so much smaller than industrial cutters. Besides, the problem is com- 
plicated by the subjective element introduced by the patient. The primary 
aim of the NBS work in this field has been to discover how the rotating 
dental instrument may be most effectively operated without injuring vital 
• structures through high temperatures or vibration and with minimum 
discomfort to the patient, A second aim has been to gather data for use 
by the Armed Services in specifying standards for procurement of rotating 
dental instruments. 

Previous work has shown that vibrations applied to teeth in the fre- 
quency range between 100 and 300 cycles per second produce the most 



Medical News Letter, Vol. 26, No, 8 



25 



unfavorable patient response. Unfortunately, frequencies in the range 
100 to 200 ops are dominant in eccentric burs rotated at 6000 to 10, 000 
rpm - speeds now used by many practitioners. The NBS investigation 
attempted to find out what degrees of bur eccentricity at what speeds 
cause vibrations in the distressing range. 

In order to do this, a number of steel and carbide burs and diamond 
abrasive wheels from various suppliers were studied. It was found that 
a true-running eight-bladed bur rotating at 10,000 rpm produced eight 
low-amplitude peaks per revolution at a frequency of 1330 cps. However, 
a similar but eccentric bur rotating at the same speed produces a funda- 
mental frequency of 166 cps with amplitude proportional to the amount of 
eccentricity. 

The data regarding vibration will be applied to clinical practice as 
rotating instruments are improved. If eccentricity of dental burs is kept 
small and symmetry of cutting heads increased, the chatter and vibration 
in the range of frequencies most annoying to patients can be reduced. 
However, even the most accurate bur will not perform properly in a hand- 
piece that does not operate smoothly. Therefore, the Bureau plans to 
study the effect of the handpiece on vibration in the near future. 

In the course of the study on rotating dental instruments, the rela- 
tive cutting ability of steel and carbide burs and of diamond abrasive 
wheels was compared. The results showed that diamond instruments 
cut tooth enamel more rapidly at speeds of 10, 000 rpm than 5000 rpm. 
Diamond wheels are many times more efficient than either steel or 
carbide when cutting tooth enamel. The cutting rates of both steel and 
carbide burs are similarly improved at the higher speed when cutting 
dentin. Carbide burs cut dentin at about twice the rate of steel burs at 
10, 000 rpm. In general, high speed rotation enables dental instruments 
to cut teeth' faster with less pressure and with lessened probability of 
damage to tooth structure when proper cooling is employed. Many den- 
tists also feel that better control of the instrument results when high rota- 
ting speeds are used. (National Bureau of Standards, September 1955; 
D. C. Hudson, J. L. Hartley, R. Moore, W. T. Sweeney) 

* * * * * * 
Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U.S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addresses. 

:(< ^ s(: s{! ^ :5c 



/ 



26 



Medical News Letter, Vol. 26, No. 8 



From the Note Book 

1 Rear Admiral B. W. Hogan, MC USN, Surgeon General of the Navy, 
will attend the 66th Annual Meeting of the Association of American Med- 
ical Colleges, October 24 - 26, 1955. Admiral Hogan will also attend the 
meeting of the Executive Council of the Association on October 22, at 
which time he will address the Council on "The Navy Medical Department. " 
He will meet with the Council, the members of the Committee on Planning 
for National Emergency, and with the members of the Joint Committee on 
Medical Education in Time of National Emergency. (TIO, BuMed) 

2 Rear Admiral H. Lamont Pugh, MC USN, relieved Rear Admiral 
Leslie O. Stone, MC USN, as Commanding Officer of the National Naval 
Medical Center, Bethesda, Md. , on September 30, 1955. (TIO, BuMed) 

3 Commander P. C. Wilson, MSG USN, Executive Assistant to the Direc- 
torate for the Armed Servic es Medical Procurement Agency, recently 
received a citation from the Commission on Organization of the Executive 
Branch of the Government, signed by its Chairman, Herbert Hoover. The 
citation expressed the sincere appreciation of the Commissioners for the 
notable contribution which Commander Wilson made to their joint work on 
the Commission. (TIO, BuMed) 

4 Commander R. B. Williams, Jr., MC USN, presented a lecture entitled, 
"Mechanisms Involved in Ionizing Radiation Injury and Radiotherapy, " at a 
joint meeting of the Forsyth and Guilford Medical Societies, and to the stu- 
dents of the Bowman Gray School of Medicine in Winston Salem, N, C. , 
October, 11, 1955. Commander Williams is the Head of the Pathology 
Division of the Naval Medical Research Institute, NNMC, Bethesda, Md. 
(TIO, BuMed) 

5 Lieutenant R. Gorlin, MC USNR, will deliver a professional paper and 
participate in a panel discussion at the 28th Annual Scientific Sessions of 
the American Heart Association in New Orleans, October 22 - 24, 1955, 
The paper is entitled, "A Simple Clinical Test for Detection of Altered 
Cardiodynamic s of Left Ventricular Failure and Mitral Stenosis. " The 
panel discussion is entitled, "Hemodynamics in Relation to Heart Surgery. " 
LT Gorlin is the Medical Officer in Charge of the Cardiopulmonary Function 
Laboratory, Naval Hospital, Portsmouth, Va. (TIO, BuMed) 

6 October Historical Calendar. October 1, 1850 , S.R. Addison appointed 
Assistant Chief of the Bureau of Medicine and Surgery . . . October 1, 1897 , 
Newton L. Bates appointed 15th Chief of Bureau of Medicine and Surgery . . . 
October 1, 1943, former Naval Hospital, Shoemaker, Calif. , commissioned 

. . . October 2, 1944, former Naval Convalescent Hospital, Banning, Calif. , 



Medical News Letter, Vol. 26, No. 8 



27 



commissioned. . . October 9, 1873 , U.S. Naval Institute founded . . . 
October 10, 1845 , U.S. Naval Academy opened . , . October 12, 1911, 
Naval Hospital, Great Lakes, commissioned . . . October 15, 1948, 
first woman doctor commissioned in Regular Navy, Commander Francis 
L. Willoughby . . . October 17, 1944 , former Naval Hospital, Astoria, 
Oregon, commissioned . . . October 18, 1867 , Alaska purchased . . . 
October 19. 1942 , Naval Hospital, Key West, Florida commissioned . . 
October 20, 1954 , first Medical Service Corps officer. Captain Fay O. 
Huntsinger, selected for promotion to grade of Captain . . . October 28, 
1878 , J. Winthrop Taylor, appointed 10th Chief of Bureau of Medicine and 
Surgery. (TIO, BuMed) 

7 AlNav 73 emphasizes the importance of annual physical examinations 
as a means for detecting disease processes in their incipiency and thus 
permitting early institution of corrective measures. Maximum benefits 
from such examinations require scrupulous care in conducting the exam- 
ination, the exercise of sound clinical judgment in interpreting results, 
accurate reporting of results, and cooperation of officers examined with 
respect to recommendations for additional study or treatment. 

8 The Public Health Service has announced ten grants totaling $295, 367 
to start a special program of research into air pollution problems. The ten 
grants were awarded by the Surgeon General on recommendations of the 
National Advisory Health Council from a $500, 000 fund appropriated this 
year by Congress to the Department of Health, Education, and. Welfare. 

(P. H. S. , Dept. H. E. W. ) 

9 A course in Forensic Pathology will be given November 14 - 18, 1955. 
at the Armed Forces Institute of Pathology. The course is designed to 
familiarize pathologists with the problems of Legal Medicine and the role of 
the pathologist in the solution of such problems. The course is open to path- 
ologists of the Armed Forces, Federal agencies, and civilians. Application 
by civilian pathologists to attend this course in Forensic Pathology should 
be forwarded to the Director, Armed Forces Institute of Pathology, Washing 
ton 25, D. C. Pathologists m the military and other government services 
should apply via the appropriate channels of their respective service. 
(Armed Forces Institute of Pathology) 

10 Pleurobiliary and bronchobiliary fistulas are caused by penetrating 
abdominothoracic wounds, obstruction of the biliary ducts in conjunction 
with calculus, secondary infection, or strictures due to surgical injury. The 
acute phase must be treated promptly by adequate drainage to correct the 
intrathoracic dynamics (or in case of bronchobiliary fistula) to prevent a 
serious necrotizing bronchitis and pneumonia. Secondary operation on the 
biliary tract and even pulmonary resection may be necessary to cure these 
serious and unusual conditions. (J. Thoracic Surg. , Sept. 1 955 ;H. D. Adams , 
M.D. ) 



28 Medical News Letter, Vol. 26, No. 8 



BUMED INSTRUCTION 6710. 20 3 October 1955 



From : 


Chief, Bureau of Medicine and Surgery- 


To: 


All Ships and Stations 


Subj: 


Defective medical and dental material; authority for disposition of 


Ref: 


(a) Medical and Dental Materiel Bulletin, Edition No. 58 




of 1 Sep 1955 




(b) Art. 25-21, ManMedDept 



This instruction provides authority for the disposal of defective material 
listed in paragraph IV of reference (a), and such additional material as noted. 

BUMED INSTRUCTION 11110. 1 3 October 1955 

From: Chief, Bureau of Medicine and Surgery 

To: Stations Having Medical/Dental Personnel Regularly Assigned 

Subj: Fixed medical treatment facilities; classification, nomenclature, 
definition, and redesignation of 

This instruction promulgates classification, nomenclature, and definitions 
applicable to fixed medical treatment facilities revised in accordance with 
current instructions of the Department of Defense, and to redesignate exist- 
ing medical facilities of the Navy Department in conformity therewith. 

j^c sjs 1^ ^ 

BUMED NOTICE 6230 7 October 1955 

From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Medical Department Personnel 
Regularly Assigned 

Subj: Influenza vaccine; use of 

This Notice provides information concerning utilization of influenza vaccine 
by military activities during winter of 1955 - 1956. 



JJC * * * Jl! * 



Medical News Letter, Vol. Z6, No. 8 



29 




MEDICAL RESERVE SECTIO!\ 



Seminar for Commanding Officers of Reserve 
Medical and Dental Companies 

A seminar for commanding officers of nonpay medical and dental 
companies is scheduled to convene at the Bureau of Medicine and Surgery 
on Monday, 31 October 1955, and will continue through Saturday, 5 November 
1955. . 

The seminar is planned to provide indoctrination and orientation of 
the Naval Reserve Program from Bureau level with particular emphasis . 
on the medical components. Field trips to the National Naval Medical 
Center, the Potomac River Naval Command, and the Armed Forces Insti- 
tute of Pathology will be conducted. A series of conferences will be held 
between those in attendance and the officers in the Bureau with a view for 
an improved Reserve Program through the exchange of ideas and recom- 
mendations. 

The commandants of all continental naval districts and the Potomac 
River Naval Command have been assigned a quota for this seminar. 

:{c 9|c ^ ^[c 

On-the-job Training in Submarine Medicine 

A 14-day, active duty training course in Submarine Medicine is 
scheduled to convene at the U. S. Naval Medical Research Laboratory, 
Naval Submarine Base, New London, Conn. , on Monday, 7 November 1955. 

This course of on-the-job training presents an up-to-date review of 
problems relating to Submarine Medicine and includes recent developments 
in Submarine Research. Quotas for this course have been assigned to Com- 
mandants of the First, Third, and Ninth Naval Districts. All Naval Reserve 
Medical and Medical Service Corps officers are eligible to attend. 

Ten days' advance notice to the Commanding Officer, Submarine Base, 
and the Officer in Charge, Medical Research Laboratory, New London, Conn. , 
is required so that accommodations may be made available. Quarters, mes- 
sing and off-duty recreation facilities are available on the base. Off- station 
accommodations are limited. Orders should direct the trainee to report 
prior to 1600 on the date preceding the convening of the course. Secret 
clearance is required. 



4: ^ ^ 9|: 4: sSc 



30 



Medical News Letter, Vol. 26, No. 8 



Gratuitous Points 



Did you know that your 15 "gratuitous points" are prorated according 
to the amount of active duty or active duty for training you perform, in 
computing each year of satisfactory Federal service for retirement pur- 
poses? 

If you take the normal tour of 14 days' ACDUTRA, you lose one 
gratuitous point. Reservists who operate on a slim margin of safety - 
that is, those who try to hit the 50-retirement-points - each-year require- 
ment right "on the nose" - should consider this technicality when planning 
their satisfactory year of Federal service. 

A recent decision by the Comptroller General provides that "in each 
year of E ederal service after 30 June 1949, there be deducted the number 
of days of active Federal service in order to determine what portion of the 
15 day$ (gratuitous points) may be credited in such year for service in an 
.active Reserve component. " Active Federal service has been defined for 
this purpose as active duty and active duty for training. 

The following table shows the number of gratuitous points which may 
be awarded, based on the Reservist's periods of active duty or ACDUTRA: 

Days Active Duty Gratuitous Points 

or to 
ACDUTRA Awarded 





15 































































(The Naval Reservist, August 1955) 

:Jc ;{! * * * 3}: 



Medical N*ews Letter, Vol. 26, No. 8 
AVIATION MEDICINE SECTION 



31 




Course in Aviation Medicin e 

The Bureau of Medicine and Surgery announces that a class in Avia- 
tion Medicine will convene at the U. S. Naval School of Aviation Medicine, 
Naval Air Station, Pensacola, Fla. , on 2 April 1956. The course consists 
of approximately 6 months of academic instruction in aviation medicine 
and flight indoctrination training, and leads to the designation of success- 
ful candidates as U.S. Naval Flight Surgeons. 

The class will be limited to 30 students and is open to medical officers 
of the Regular Navy and Naval Reserve in the ranks of Lieutenant Commander 
or below. 

Medical officers who wish to apply for the Course in Aviation Medicine 
should do so by an official request via the chain of command to the Chief of 
the Bureau of Medicine and Surgery which shall contain this service agree- 
ment: "If this request is approved, I agree to remain on active duty for 
one (1) year upon completion of the Course in Aviation Medicine, or for 
six (6) months beyond my currently obligated service, whichever is longer. " 
(AvMedDiv, BuMed) 

:4c >|c :4i 4i :jc >Ec 

The Air Development Squ adron 

Many flight surgeons have shown interest in some new developments 
of Naval Aviation and found information difficult to gain. The Navy's air 
development squadrons (of which there are 6) serve as a test bed and eval- 
uation team for new aircraft, equipment, and tactical procedures. Since 
I have been attached to Air Development Squadron 3 (VX-3) for the past 
18 months and have been privileged to participate in much of the flight 
evaluation, it was requested that I take this opportunity to pass on to 
other flight surgeons information concerning the projects this Squadron 
has been conducting. 

First, in order to make the c inclusions of a project valid for present 
and near -future air groups, all types of aircraft must be included. In VX-3, 



32 



Medical News Letter, Vol. 26, No. 8 



the stress is on jet fighters; and thus, the F9F-8, F2H-3, F2H-4, FJ3, and 
F7U-3 are flown, as well as the AD-5N and AD-6 in some special work. 

The most recently completed project was a field and shipboard eval- 
uation of the "mirror" or visual reference landing aid. This system of 
carrier landing for day and night operations has proved practical, and 
further intensive training and evaluation is now being carried out by fleet 
squadrons aboard the USS Bennington. The mirror is in fact, just that: 
a large but precisely made polished alurhinum surface with dimensions 
of 4 feet by 5 feet, being vertically flat and horizontally concave. Next 
to the mirror laterally are two rows of "datum" lights. The mirror is 
mounted halfway along the port side of the ship's canted deck and rises 
approximately 8 feet above the landing surface, facing aft toward the 
groove. A source light is mounted 160 feet astern of it, about level with 
the landing area. By angling the mirror slightly upward, a visual glide 
path reflection of the source light, sloping 4 to 5 degrees relative to the 
deck is established. As long as a pilot flying down the groove keeps the 
source light centered on the mirror with reference to the datum lights, he 
will clear the ramp well and pick up number 3 wire every time. If he is 
high, the ball of light shows high and he can correct easily, the same being 
true for low indications. If the six wires are missed, the "go-around" is 
easily accomplished off the angled deck since engine power is never reduced 
unless the wire is caught. The approach is very comfortable, being about 
200 feet higher than the standard pattern throughout and having a steady 
descending straightaway which allows excellent visibility: a "plan" view 
of the carrier deck. Wave-off is given by flashing red lights located along 
the side of the mirror. These are actuated by the Landing Safety Officer 
(Landing Signal Officer) who is not specially trained for the job, but need 
be only an experienced carrier aviator. All pilots have agreed that this 
landing system coupled with the canted deck is far superior to present 
methods of carrier landing, and they are psychologically more confident 
when coming aboard. These two innovations were developed by the British 
Navy and have been used successfully by them. 

A development in the field of navigation and instrument flight with 
which the squadron has worked is TACAN. In this system, a transceiving 
antenna, located ashore or afloat, emits signals which enable electronic 
"black boxes" in the aircraft to present to the pilot his azimuth (magnetic 
bearing) and distance from the station up to about 200 miles, line of sight 
at altitude. With these two bits of information, precise broadcast control 
fighter interception can be made; the accuracy being great enough to reliably 
bring an interceptor to within the short sighting range needed for visual 
contact of target aircraft at high altitudes and speeds. As an incidental 
point, this work has shown, however, that the human eye for sighting will 



Medical News Letter, Vol. 26, No. 8 



33 



be inadequate under future combat conditions, and concentration of RADAR- 
like electronics aids will be essential. With TACAN equipment, jet fighters 
can rendezvous on course at cruising altitude after as much as one minute 
interval take-offs and penetration of IFR weather, a procedure which with- 
out the distance and bearing information in such an accurate form is almost 
impassible to accomplish. Also, a large number of aircraft can make safe, 
closely spaced penetrations of overcasts down to several hundred feet and 
land aboard ship or on the field in rapid succession, a most important con- 
sideration for gas -gulping turbo- jets. If this equipment proves out as 
satisfactorily as it now seems to be, the all-weather and tactical potential 
of our fleet aircraft will be greatly augmented. 

In another VX-3 project, the probe and drouge method of refueling 
fighter aircraft was evaluated as to its effectiveness for range extension; 
and the problems of rendezvous with a tanker plane using present naviga- 
tional aids were investigated. 

As the flight surgeon, I have looked into these projects and others, 
seeking methods for improving pilot effectiveness, comfort, and safety. 
In a project concerning long range, low level navigation flights (100 feet 
over the terrain for up to 12 hours), methods for relieving pilot fatigue 
with special in-flight food, drugs, and seat pads were studied. My own 
muscular spasms and macerated buttocks after these flights attested to 
the acuteness of the problem. This experience is highly recommended to 
any flight surgeon who wishes to glean the wisdom of Aesculapius in dealing 
with pilots' "hypochondria. " Dexedrine Spansules were found to be an effic- 
ient medication for combating fatigue and for best results, were taken about 
5 to 6 hours before expected landing time. A special woven plastic seat, 
provided for evaluation by the Aeronautical Medical Equipment Laboratory 
(AMEL), proved a simple and practical aid for seating discomforts. 

The pilots of VX-3 also have assisted AMEL in the evaluation of 
several new single-piece protective helmets (M. S. A. , H-5, and B. B, C. 
types), eye shields and goggles, and winter and summer flight suits. 

We have also had close liaison with the Aviation Medical Accelera- 
tion Laboratory at Johnsville, Pa. , and are collecting for them three- 
dimensional, G timegraphs of our jet fighters in aerobatics and combat 
maneuvers, as well as steam and hydraulic catapult launches and carrier 
arrested landings. The actual G patterns, experienced by aviators of 
modern jet fighters, can thus now be accurately simulated on the centrifuge. 
(LT Frank H. Austin, Jr., MC USN, VX-3, NAS, Atlantic City, N.J.) 



34 



Medical News Letter, Vol. 26, No. 8 



ATTENTION ALL FLIGHT SURGEONS ! 

BE PREPARED FOR OPNAV INSTRUCTION 3740. 3AI 

Printing and distribution of the new OpNav Instruction 3740. 3A 
should be accomplished within a few weeks. Look for it. It contains the 
ground rules for implementing a strengthened Aviation Physiology Training 
Program. It is important to all flight surgeons, and you will want to brief 
your commanding officer and flight personnel on the differences between it 
and 3740. 3, the subject of which was Aviation Oxygen Training Qualifications. 

The objective of this instruction is to train flying personnel so that 
they will be prepared in every respect to cope with the hazards of flight 
which they may encounter. 

Flight surgeons recognize that a thorough knowledge of aviation 
physiology and proficiency in the use of personal protective equipment are 
prerequisites to safety of flight and the success of a military mission. 
This instruction strengthens your hand in the practice of your specialty. 
Like Captain A. G, Lamplugh (RAAF), you will say: 

"Aviation is inherently safe, but, to an even greater extent 
than the sea, is terribly unforgiving of any incapacity, careless- 
ness, or neglect. " 

Commanding officers look to the flight surgeon for assurance that 
flying personnel are fit and ready for the flying job at hand. In effect, 
the flight surgeon's task is to ferret out the incapacity, carelessness, or 
neglect among his fliers and do something about it. "3740. 3A" will assist 
you. 

You, the flight surgeons of the Fleet, have written this instruction. 
How? Well, you began by submitting the Medical Officers Report of 
Aircraft Accidents. You reported that pilots were diving into the ground 
from 30, 000 feet with no attempt at recovery. The cause? Probably 
some carelessness or neglect involving oxygen equipment or use. When 
was the victim's last low pressure chamber run? Could you assure the 
commanding officer that the pilot was thoroughly checked out in his oxygen 
gear ? 

You reported that pilots who had never been in an ejection seat 
trainer were trying to get out of a disabled jet. Hardly the time to learn 
how - those few available seconds in an emergency! Could you assure the 
commanding officer that the pilot knew his ejection seat mechanism as 
intimately as his shoestrings? 

And, you reported many cases of vertigo, night blindness, and 
sensory illusions of flight which were the apparent causes of fatal accidents. 
The pilot who is unprepared to cope with these hazards is about as effective 
as a blind surgeon. 



Medical News Letter, Vol. 26, No. 8 



35 



As a result of your reports, requirements for training in aviation 
physiology, oxygen breathing equipment, protective equipment, night vision, 
and use of the ejection seat have been written in some detail. Every flight 
surgeon should know the requirements by heart. 

In addition, you will note that the flight surgeon is mentioned in the 
same phrase with the commanding officers: "Commanding officers and 
flight surgeons should recognize the continual nature of the training re- 
quired by this Instruction ..." Where the safety of flight is concerned, 
the flight surgeon is quarterback on the team. You can't play the game 
without the signals in 3740. 3A. 

9|e >}; sjc it: :{c 

National Air Show Exhibit 

The National Air Show, which was held at Philadelphia, Pa. , on 
3-4-5 September, included an aeromedical exhibit consisting of panel 
exhibits from the U.S. Naval School of Aviation Medicine, the Aviation 
Medical Acceleration Laboratory, the Aeronautical Medical Equipment 
Laboratory, and the Bureau of Medicine and Surgery. It is estimated 
that over 300, 000 people visited this exhibit. Special interest was shown 
in the demonstration of the Navy's new full pressure suit and the ejection 
seat capsule. 

3{C !{C ^[f SjC af* 

Examinations of Pilots Following Hospitalization 

Numerous examples of failure of flight surgeons to submit proper 
posthospitalization flight physicals has come to the attention of BuMed. 
All pilots upon reporting for duty following a serious injury or illness 
and hospitalization will, prior to return to a flight duty status, be examined, 
and the original and one copy of the report of such examination shall be 
forwarded to the Bureau of Medicine and Surgery for approval. 

(Flight surgeons are referred to the Manual of the Medical Department, 
Chapter 15-70, paragraph Z. ) 

9jc 9j< »}: j): 

Respiratory Chemistry - Gaseous Exchange 

To a visitor from outer space,, the whole phenomenon of human res- 
piration is utterly impossible on the face of it. Not a single cell on the 



36 



Medical News Letter, Vol, 26, No, 8 



body surface (or even the cornea) is alive; hence, there is simply no way 
for the body to obtain from the surrounding atmosphere the 250 cc. of 
oxygen it needs each minute while at rest, to say nothing of 10 times as 
much during exertion. 

For a one-celled creature, it is feasible; for an elaborate mammal, 
it is out of the question unless two peculiar devices are utilized. One of 
these, obviously, is the blood circulation; the other is a curious metal- 
containing, porphyrin compound that officiates in gaseous exchange every- 
where on earth: It occurs with magnesium as chlorophyll in the vegetable 
kingdom, and with iron as cytochrome and hemoglobin in the larger self- 
propelled creatures. 

Efficiency 

Man presents to the atmosphere a live area some 50 times as great 
as the body surface - up to 100 square meters - in the form of the pulmon- 
ary alveoli. They afford an admirable ar ea for gaseous exchange in keeping 
with the remarkable chemistry of hemoglobin. However, the remainder 
of the respiratory system is lackadaisical in arrangement and nowhere 
approaches a striking level of efficiency. For instance, the movement of 
air in the human lung is tidal and all that this signifies in terms of dead 
space. The composition of the atmosphere is, itself, only pas sable, so 
that without artificial aids man is obliged to live within a few thousand 
feet of sea level. 

But these deficiencies are largely overcome by the complex behavior 
of the hemoglobin molecule, which in a group of reciprocal reactions, takes 
up oxygen at its alveolar tension (100 mm. Hg), yields it at the lower oxy- 
gen pressure in tissues (1 to 60 mm, Hg) and counterbalances the chemical 
changes associated with movement of CO2 at either site. It is true that 
a little oxygen, 0. 3 volumes per 100 cc. , is carried in simple physical 
solution in the blood plasma, but some 20 volumes per 100 cc. is trans- 
ported by red cell hemoglobin that leaves the lung at close to saturation 
(97. 5%)i When the arterial blood reaches the tissue capillaries, its oxygen 
tension is so much higher than that of its environs that the oxygen diffuses 
from the plasma across the capillary membranes, oxygen tension of the 
capillary plasma falls, and O2 is, therefore, released from the loose 
oxyhemoglobin combination. Thus, a steady flow of oxygen from red cell 
to tissue cell is impelled by the considerable gradient between them; in 
a sense, oxygen, like water, runs down hill. 

The S-Shaped Curve 

The remarkable S-shaped oxygen-dissociation curve of blood (left) 
is such that the lower the oxygen tension in tissues, and the greater the 
need for oxygen, the more amenable is hemoglobin to yielding its store 



Medical News Letter, Vol. 26, No. 8 



37 



of oxygen. Thus, with a tissue at rest and an oxygen tension of about 40 mm. 
Hg, some 5 volumes per 100 cc. of oxygen is given up by the hemoglobin. 
However, in severe oxygen depletion (as in muscular activity), when the 
oxygen tension of the tissue fluids and cells may be as low as 1 mm. Hg, 
the curve shows that hemoglobin can yield almost all of the 20 volumes per 
100 cc. of the oxygen that it has stored. 

The position of this curve, moreover, is influenced by pH; in a more 
acidic medium it shifts to the right, so that given a certain oxygen tension, 
more oxyhemoglobin becomes dissociated. Now, in the tissues where CO2 
is being released, acidity increases, with the result that hemoglobin is 
exquisitely prone to deliver oxygen where it is needed. 

The management of CO2 transport is likewise admirable. The CO^ 
that enters the blood from the tissues is most rapidly (and reversibly) con- 
verted into H^CO^ by virtue of the enzyme carbonic anhydrase which is 
present in the red cells (not in the plasma). Thus, CO2 / 

Only a relatively limited amount of CO2 could be transported in this 
fashion unless the partial pressure of CO2 were very high, and an intoler- 
able acid pH developed. Fortunately, the buffer systems in the blood - 
primarily the blood proteins - are weaker acids than H2CO3 and so prefer- 
entially yield their cations while binding hydrogen ions. The leading member 
of these buffer systems is hemoglobin itself, constituting about three-fourths 
of the total blood protein. What occurs can be summarized as: H2CO^ 
/ KHb ^ HHb / KHCO3, with the KHCO3 in the form of cation and anion, 
K/ and HCO-j". Thus, practically all of the carbonic acid (H2CO-J) forms 
bicarbonate so that the amount of H2CO2 itself in the blood is very small. 

A remarkable characteristic of hemoglobin is that its di d sociability 
varies with oxygenation, oxyhemoglobin being more active or more dissoc- 
ciated, or a stronger acid, than reduced hemoglobin. Thus, when oxyhemo- 
globin becomes reduced hemoglobin in the tissues, it is even more avid to 
bind the hydrogen ion from H2CO3 and make its potassium ion available for 
potassium bicarbonate. In the lungs, on the other hand, oxyhemoglobin is 
formed, and hydrogen ions are dissoriated from it so that H ^ / HCO^ ~ 
H2 CO3 H2O / CO2 . and the CO2 is driven from the blood. 

Another important Ciiaracteristic of hemoglobin is that it also directly 
combines with CO2 by means of one of its amine(NH2) groups, to form so- 
called carbhemoglobin. This reaction proceeds from CO2 itself without 
H2 COj as an intermediary. Reduced hemoglobin combines with CO2 
much more avidly than oxyhemoglobin, so that here again is a reversible 
reaction calculated to take up CO2 from the tissues and release it in the lungs. 

In addition to these mechanisms, CO2 is physically dissolved in blood 
plasma, but this simple solution accounts for only some 5% of CO2 carried 
in the blood. 

These, in brief, are the chemical interrelations that make gaseous 
exchange possible. There are other wonderful facets. 



38 



Medical News Letter, Vol. 26, No. 8 



Other Controlling Factors 

The central nervous system, in its normal control of respiration, 
is sensitive to, and operates primarily according to, the titer of CO2 
(the oxygen level comes into play as a controlling influence only in extreme 
respiratory disability). Another facet of the movement of CO2 entails pas- 
sage of HCO3 — in and out of the red cell, which has a cell membrane 
permeable to it but not to corresponding amounts of cations; hence a move- 
ment of chloride ion in the reverse direction (chloride shift) occurs and 
serves to equalize the ionic balances. 

Thus, if there is a single physiologic function that illustrates how 
ingeniously a living organism can survive and operate, using the subtleties 
of chemistry and physics, it is the system of gaseous exchange. (J. A.M. A. , 
159: 26-27, September 10, 1955) ( Pfizer Spectrum ) 

^ ^ ■'5^ ^ ^ 

Symposium on Physiologic and Pathologic 
Effects of Microwaves 



A Symposium on the Physiologic and Pathologic Effects of Microwaves 
was held at the Mayo Clinic, Rochester, Minn , , on. 23 - 24 September. The 
purpose of this meeting was to bring together interested individuals from 
industry, medicine, research activities, and the military for discussions 
on the status of activities in this field and suggest further lines of future 
research. At the same time, it was hoped that some clarification would 
be made of the damage risk criteria in connection with exposure to this 
form of radiation. 

From the military point of view, the presence of intense microwave 
radiation near the source of high powered airborne radars makes the 
exposure to these beams a potential hazard, and flight surgeons, attached 
to units possessing aircraft having radar equipment of high power, should 
be conversant with the safety factors involved. Attention is invited to the 
Bureau of Aeronautics CONFIDENTIAL Technical Note 17-54 and CONFI - 
DENTIAL Technical Order 24-55. 

A paper was presented at the Mayo Clinic Symposium by Commander 
Sidney I. Brody, MC USN, which outlined the interests of the military 
services in the biological effects of microwave radiation. Fundamentally, 
the major considerations in this regard center on safety precautions and 
methods to prevent accidental injury to personnel. LT T. S, Ely, MC ySN, 
of the Naval Medical Research Institute, in a well received paper with 
co-author LTCDR David Goldman, MSC USN, discussed the result of inves- 
tigations into the heating effects of microwaves on animals exposed to radar 
beams. 



Medical News Letter, Vol. 26, No, 8 



39 



The Symposium pointed, out the need for further research into the 
action of microwaves of various frequencies on living tissue, and empha- 
sized the requirement for the establishment of criteria concerning the 
field density of this nonionizing radiation for use in industry where expos- 
ures may be continuous, in medicine for use in conjunction with the opera- 
tion of the microwave diathermy, and in the military where accidental 
exposures may be expected to be of short duration and of higher magnitude. 

Histo rical Facts of Interest for October 

1 October 

1955 The Navy announced the successful flight of the XP6M-1, 

the new 600 MPH jet seaplane called the "Martin Seamaster. " 

1946 The Navy plane "Truculent Turtle" set a record for nonstop 
long distance flight, completing an 11,236-mile trip from 
Perth, Australia, to Columbus, O. , in 55 hours and 15 minute 



2 October 

1942 The first flight by turbojet aircraft in the United States was 

made at Muroc, Calif. , by Bell P-59A with General Electric 
I-A engine. 

3 October 

1918 Flight refueling was demonstrated by L,T Godfrey L. Cabot, 
USNR, who lifted 155 pounds of weights into his Burgess- 
Dunne seaplane from a moving sea sled. In a second flight 
exactly two years later Cabot picked up a 5 -gallon can of 
gasoline from a float in the Potomac River near Washington, 
D. C. 

5 October ' 

1905 Orville Wright flew 24. 2 miles in 38 minutes and 3 seconds 
at Dayton, O. , establishing a world distance and duration 
record. , 

6 October ; . , .. ;•■ . 



1923 LT A. J. Williams, USN, flying a Curtiss Racer at St. Louis, 



40 



Medical News Letter, Vol. 26, No. 8 



set a new world, speed record of Z43. 8 MPH for 100 kilo- 
meters, and 243. 7 MPH for 200 kilometers over a closed 
circuit, 

8 October - 

1912 The first Navy physical examination for pilots was published 
by the Bureau of Medicine and Surgery. 

15 October 

1924 ZR-3 (later renamed the "Los Angeles"), the first dirigible 
sent to the U. S. Navy from Germany under reparations 
agreement, arrived at Lakehurst, N. J. 

19 October 



1948 The Navy announced that photographs of the earth's surface 
had been taken from altitudes between 60 and 70 miles by 
cameras installed in rockets. 



25 October 



1911 LTS T.G, EUyson and J. H, Towers USN established an 
unofficial nonstop seaplane record of 138. 2 miles from 
Annapolis, Md. , to Buckroe Beach, Va. , in 2 hours and 
27 minutes. 

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